The psychoneuroses and their treatment by psychotherapy

Front matter

YALE MEDICAL LIBRARY

HISTORICAL LIBRARY

THE PSYCHONEUROSES

Preface

When, more than thirty years ago, I began to devote myself to the study of diseases of the nervous system, I was struck, from the very beginning of my practice, with the slight success which resulted from treatment of neuropaths by medicines, whether combined or not with physical measures, and little by little I was led, by personal experience, to ask myself whether it would not be wise, in the case of all patients coming under the classification of neurasthenia or hysteria, to depart from the usual therapeutic methods, and seek the cause of their disease outside of the objective symptoms which they presented.

I thus became more and more convinced that it was not the physical, but rather the moral which was the cause of all the symptoms of which these patients complained, and finally, after having practised Dr. Weir Mitchell's methods for several years, my convictions were established. In using this method of treatment, which is based practically on isolation, rest in bed, over-feeding, douches, massage, and electricity, in fact on purely physical measures, I was not long in discovering that unless the patient's state of mind improved the therapeutic results were far from satisfactory.

It was thus that I soon came to see that in order to treat neuropaths, with the hope of curing them, the first and most important thing was to get hold of their morale, in other words, to practise psychotherapy. This is what I have been doing for the last twenty-five years.

The influence of the morale on the physique has been known in all ages. It is in fact a popular belief that the health may be seriously affected by grief or vexation, but physicians have been, as a rule, the last persons to recognize that these might be connected with a very special class of affections, requiring particular treatment, based not on symptoms but on causes: and, without wishing to deny — at least in many cases — the accuracy of the old adage "Mens sana in corpore sano," I nevertheless believe that, in the case of most neuropaths, whatever may be their symptomatology, the saying is not correct. With them, as a matter of fact, if the body is not sound it is because their morale is unhealthy, and because they have either suffered or are still suffering morally or spiritually.

As a method of general education, or moral guidance, psychotherapy is as old as the world. All philosophies, and all religions, above all, the Catholic religion — for the psychotherapist is nothing more than a confessor, or director of the lay conscience — have applied it, or are still applying it. Few, however, are the physicians who understand this, or who know how to make use of it, when they know the cause.

vi PREFACE.

To be convinced of this, one only has to see what a large number of neuropaths are being subjected to some physical treatment, as if they had some true organic lesions. I am alluding to those patients, whose number is legion, whom I have described under the name of false gastropaths, false enteropaths, false cardiopaths, false genitopaths, sufferers from spinal disease, and false cerebral disease; who present symptoms which often seem serious, but whose origin is wholly psychic, and who are treated every day purely and solely on the lines of symptomatic therapy, with the result that the idea becomes more firmly fixed in their minds, that there is some disease localized in the organ of which they complain. I have seen thousands of these invalids.

I hold that the physicians who understand and know how to practise psychotherapy are still very few in number. I do not, however, consider direct suggestion as a psychotherapeutic measure, either when produced more or less openly in the waking state or by means of hypnosis. Such methods have the serious defect of acting only on the subconscious, and on the cerebral automatism, and are not directed to the superior faculties of the individual.

Suggestion, though much more frequently used in hysterical cases than in troubles of neurasthenic origin, whether practised in the waking state or during hypnotic sleep, is directed only to the symptom, and not to the cause ; its action is only on the surface, it does not reach the depths. By this process one often succeeds more or less quickly, in certain cases, in getting rid of a paralysis, a contracture or an anaesthesia in an hysteric. But, without taking the drawbacks into consideration, and they are very numerous, the result is very uncertain, unless, by winning the confidence and appealing to the reason of the patient, or in other words by means of psychotherapy, one succeeds in making him confess his manner of living, and explains to him how and why he fell ill, and how and why he can become cured, so that he will not relapse.

Even though these methods, which are directed only to the cerebral automatism, are sometimes successful in causing some of the objective manifestations of a hysterical condition to disappear, they are absolutely without efficiency when it comes to the very complex and intricate symptoms of a neurasthenic. For here the mental condition is wholly different. One cannot cure a false gastropath or cardiopath by a brusque command. It is a case for mental pedagogy, which often requires a long time and careful development to be effectual.

It has been stated repeatedly, and with some reason, that isolation in a sanitarium is fundamental in the treatment of the psychoneuroses. In a general way this is true, but it is not absolutely imperative. In the case of many neuropaths isolation is not necessary, and the psychotherapist need not insist on it. Isolation, in fact, is nothing but a

PREFACE. vii

means, without which, in many cases, it would be impossible to practise psychotherapy, and which has its special indications.

A sojourn in a sanitarium is possible only to the wealthy or those who are comfortably off, and is wholly out of the question for the poorer classes of society. But the psychoneuroses are not met exclusively among the well-to-do. Neurasthenia and hysteria are, in fact, very common among the working population of Paris, and are often found in very severe forms. I have therefore tried to introduce in the hospital the suitable conditions of treatment which one would find in a sanitarium, and for fifteen years I have established in my service at the Salpetriere an isolation and psychotherapeutic ward, where several thousand patients have been treated. The results obtained by this measure have far surpassed the hopes I had in the beginning, for they have proved quite as satisfactory, and even more rapid, than those in private practice. I will not go into the details of my methods of working in the hospital. The reader who is interested in this question will find all the necessary information in a work entitled "Isolement et Psychotherapie, " published in 1904, by my pupils Camus and Pagniez. I merely make, in passing, the statement that at the Salpetriere, as well as in the city, it is the moral treatment which is the cause of the success obtained.

According to some authors, particularly Dubois (of Berne), psychotherapy ought to be "rational," that is, based solely on reasoning and argument. I have always been of the opposite opinion, and I have frequently expressed myself on this subject, both in my courses at the Faculty of Medicine and in my clinical lectures at the Salpetriere. If reason and argument were sufficient to "change one's state of mind," the neuropaths would find in the writings of the moralists and philosophers, and spiritual advisers, everything they would need to reconstruct their morale, and consequently their physical well-being, and therefore they would have no need of a psychotherapist.

Reasoning by itself is indifferent. It does not become a factor of energy or creator of effort; but the moment an emotional element appears the personality of the subject whose mentality one is seeking to modify, is moved and affected by it. According to my way of thinking, it is an error to consider both the judgment, which is a primitive phenomenon, and the impression or sentiment which follows it as psychological processes of the same nature. The impression and sentiment are nothing but the result of the more or less ready adaptation of our personality to the judgment which caused them, and though secondary are no less able to provoke reactions.

From my point of view, psychotherapy depends wholly and exclusively upon the beneficial influence of one person on another. One does not cure an hysteric or a neurasthenic nor change their mental condition by reasoning or by syllogisms. They are only cured when they viii PREFACE.

come to believe in you. In short, psychotherapy can only be effective, when the person on whom you are practising it has confessed his entire life, that is to say, when he has absolute confidence in you.

Between reasoning, and the acceptance of this reasoning by the patient, there is, I repeat, an element, on the importance of which I cannot insist too strongly; it is sentiment or feeling. It is feeling which creates the atmosphere of confidence without which, I hold, no psychotherapy is possible, that is to say, unless reasoning produces effective action there is no "persuasion." I am, in fact, convinced, and have been so for a long time, that in the moral sphere the bare idea produces no effect, that is to say, the idea alone does not move one, unless it is accompanied by an emotional appeal which makes it acceptable to consciousness and thus brings about conviction. There is something analogous to faith in this, some individual element which makes the success of the psychotherapist depend upon his personality.

This is the one and only place to refer to the ancient adage — "It is faith that saves . . or cures."

I have been aided in the collaboration of this work by one of my pupils, Dr. Gauckler, with whom I have already published several works on psychotherapy.

J. Dejerine.

PL

Hi

Contents

PAGE

Introduction xiii

Chapter I. Functional Manifestations of the Digestive System 2

Disturbances of Appetite 2

A. Mental Anorexia 2

B. Quantitative Disturbances of the Appetite Due to Excess 8

C. Elective Anorexias 10

Functional Digestive Manifestations Properly' So Called 11

A. Functional Disturbances of the First Three Stages of Digestion. 11

B. Gastric Sy'mptoms in Nervous Patients 14

1. Simple Dyspepsias of Neurasthenics 16

2. Gastric Obsessions and Phobias 17

3. Established False Gastropathies 22

4. Dilatation of the Stomach in Nervous Patients 32

5. Vomiting as a Neuropathic Manifestation 34

C. Functional Troubles Connected with Defecation, and Their Con-

sequences 37

Nervous Diarrhceas 38

Neuropathic Constipation 39

Neuropathic Constipation and Diarrhcea; Their Immediate and

Ultimate Consequences 41

D. Intestinal Manifestations of Neuropaths 42

Chapter II. Functional Manifestations in the Urinary Organs 46

A. Floating Kidney in Connection with the Psychoneuroses 46

B. Modifications of the Urinary Secretion 47

C. Disturbances of Micturition 51

Chapter III. Functional Manifestations of a Genital Nature 58

A. Genital Troubles of Men 58

B. Sexual Manifestations of Women 69

1. True Genital Localizations 72

2. Female Frigidity 76

3. Neurasthenic Conditions of Sexual Origin 77

C. False Gynaecological Manifestations 79

Chapter XIV

The RAle of Emotion and Emotionalism in the Genesis of the Psychoneuroses 219

Emotional Stimuli of External Origin. Emotional Shock 219

Emotional Stimuli of Internal Origin 220

Immediate Psychological Modifications Produced by Emotional Stimuli 221 Later Psychological Actions Exercised by the Emotions. Preoccupations 223

Physical Phenomena Produced by Emotion. Anguish and Hysterical

Attacks 224

Relations Between the Psychical and the Physical Disturbances. . 227

Emotions Varying According to Individuals 228

Emotionalism and its Factors 229

Physical Conditions which Exaggerate Emotionalism 231

Individual Physical Reactions of Emotional Origin 232

The Emotions. Hysteria and Neurasthenia 233

The Nature of Emotional Causes which Engender the Psychoneuroses 236 The Factors of the Persistence of the Emotional Idea in Consciousness 239

Chapter XXIV. Special Therapy of the Various Functional Manifestations 320

I. Functional Manifestations in the Digestive Organs 320

A. Disturbances of the Appetite 320

B. Disturbances of the First Three Stages of Digestion 322

C. Gastric Manifestations of Nervous People 324

D. Intestinal Manifestations of Neuropaths: Diarrhcea and Con-

stipation 330

II. Functional Manifestations in the Urinary Apparatus 333

A. Disturbances of the Urinary Secretion 333

B. Disturbances of Urination or Micturition. False Urinaries. . 334

III. Functional Manifestations in the Genital Apparatus 336

A. Genital Troubles in Men 336

B. Sexual Manifestations of Women 342

C. Gyn.ecological Pseudo-manifestations 346

IV. Functional Manifestations in the Respiratory Apparatus 347

V. Special Therapy in Cardiovascular Manifestations 350

VI. Functional Manifestations of the Skin 351

Chapter XXV. Special Therapy of Functional Manifestations (Continued) 353

I. The Therapy of Functional Disturbances in the Neuro-muscular

Apparatus 356

A. Physical Asthenia 356

B. Disturbances of Equilibrium 358

II. Special Therapy of Disturbances of Sensibility. Pains 359

III. Therapy of the Functional Manifestations of the Organs of Sense. 361

IV. Therapy of Nervous and Psychic Manifestations Properly So Called 361

A. Disturbances of Sleep 361

B. Headache 365

C. Psychic Disturbances 366

V. Special Therapy of Hysterical Symptoms 369

Chapter XXVII

Prophylaxis of the Psychoneuroses. The Moral R6le of the Physician. Conclusions 382

Index 393

Introduction

This work is devoted td the study of the psyehoneuroses, and their treatment. In it will be found the ideas which have been formed by one of us who has spent thirty years in daily contact with neuropaths. In attending these patients, and noting the manner in which they have been treated, it has seemed to us that many physicians have held ideas concerning the nature of the psyehoneuroses that are not only incomplete and inexact, according to our lights, but are also therapeutically dangerous. This does not imply ignorance on their part, but rather that, having been brought up on doctrines and methods which are excellent in their place, they have extended their application to a branch of medicine like the psyehoneuroses, with which they have nothing to do.

All advance work in modern medicine is the direct result of progress in pathological anatomy and laboratory work. These have enabled us to get a very much more exact idea of the human mechanism, and the various troubles that may afflict it. But the fact has been quite overlooked that modifications of physical energy are not the only ones in which physicians should be interested.

All physicians rebel at the idea of any dissociation which would separate the physical organism on the one hand from the psychic and moral organism on the other. But, both instinctively, and as a result of their education, the majority of them have a tendency to subordinate the disturbances of the psychic life to those of the physical, and to always look for some initial somatic change. They refuse to even consider the existence of illnesses which owe their origin to any antecedent psychic or moral disturbance. But, there exists, according to our way of thinking, a very special nosological group, of much importance, whose symptomatology is caused solely by a primitive modification of the moral or mental state, followed by a whole series of secondary manifestations. The affections which come under this heading are known as the psyehoneuroses.

This book is wholly devoted to the development of this point of view. It will be divided into three parts.

The first, which is analytical, will be devoted to the study of functional manifestations, that is, to the study of all the symptoms which are observed in the course of the psyehoneuroses, whose exact nature we wish to ascertain.

In the second, the synthetic, we shall endeavor to make plain the general mechanism of the foundation of the psyehoneuroses, as well as their variations and nature.

In the third, which is therapeutic, will be set forth the psychotherapeutic proceedings and helps which we feel are the only measures which should be used in the treatment of the psyehoneuroses.

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PSYCHOTHERAPY

FIRST PART

Analytical Study of Functional Manifestations.

We shall study, under the name of functional manifestations, all those persistent symptoms and troubles of which neuropaths complain, and which have been created in these patients without any antecedent lesion of the body.

This definition is only provisional. It is made sufficiently broad for the moment not to limit the object of our study.

As there is no mechanism, organ, or region of the body which cannot become the seat of a functional manifestation, it would seem necessary for the various parts of the organism to be involved in equal proportions. But there are numerous reasons for the variability of frequency which exists. Without dwelling, for the moment, on the part which education, whether medical or personal, plays in the symptoms felt by these patients, we must make one statement, large in theoretic consequences, which we will make good later. Some of the functions of the body are completely automatic, and never require any direction from the superior centres. Such is the function of circulation. Others, on the contrary, especially the digestive and genital, and in part the urinary, are functions which, at least in their ultimate accomplishment, depend upon various mental representations, and call the will into play. There are functions on which the action of the will is felt, but in a purely contingent manner, such as the respiratory function. Finally, even among the functions which do not come under the influence of the will, there are none whose automatism may not be more or less affected by the influence of the emotions.

But the fact is not without significance that those very functions which are the most involved are those which are most susceptible to psychic influence.

The digestive function has always seemed to us to be the one on which the greatest number of functional manifestations were localized. With it, therefore, we shall commence our study.

Chapter I. Functional Manifestations Of The Digestive System

All of the successive acts of digestion are, to a certain degree, started going by an antecedent phenomenon, which at the outset is apparently peripheral, but which is accompanied by more or less vivid mental representations, which are known as hunger or appetite. It would perhaps be useful, in order to be exact, to make a distinction between these two words, hunger and appetite. They are not absolutely synonymous. The word "hunger" expresses some sort of organic need of nourishment. The word "appetite" expresses rather the psychic idea of nourishment. One can have an appetite without being, properly speaking, hungry. The appetite may be awakened by all sorts of purely psychic sensations, such as an odor, a savory taste, etc., ... as well as association of ideas, bearing on the time, or on places which recall the idea of food, and lead to appetite. As a matter of fact, from the point of view which interests us, the two terms may be used indifferently, and the only thing to which we attach importance is the knowledge that if this first phenomenon of digestion may, so to speak, be an outside appeal, it may also be largely dependent upon the intervention of the psychic mechanism.

Disturbances of appetite will be the first which we shall pass in review. We shall then study a whole series of functional manifestations, which may be produced at different stages of digestion.

Disturbances op Appetite.

These disturbances may be quantitative or qualitative. We shall take up successively:

A. Mental anorexia. Quantitative disturbance of the appetite due to lack of food.

B. Quantitative disturbance of the appetite due to excess.

C. Elective anorexias, or qualitative disturbances of the appetite.

A. Mental Anorexia.— It sometimes happens that a physician has patients — they are more apt to be women — whose appearance is truly shocking. Their eyes are brilliant, Their cheeks are hollow, and their cheek bones seem to protrude through the skin. Their withered breasts hang from the walls of their chest. Every rib stands out. Their shoulder-blades appear to be loosened from their frame. Every vertebra shows through the skin. The abdominal wall sinks in below the floating ribs and forms a hollow like a basin. Their thighs and the calves of their legs are reduced to a skeleton. One would say it was the picture of an immured nun, such as the old masters have portrayed. These 2 women appear to be fifty or sixty years old. Sometimes they seem to be sustained by some unknown miracle of energy; their voices are strong and their steps firm. On the other hand, they often seem almost at the point of death, and ready to draw their last breath.

Are they tuberculous or cancerous patients, or muscular atrophies in the last stages, these women whom misery and hunger have reduced to this frightful gauntness? Nothing of the kind. Their lungs are healthy, there is no sign of any organic affection. Although they look so old they are young women, girls, sometimes children. They may belong to good families, and be surrounded by every care. These patients are what are known as mental anorexics, who, without having any physical lesions, but by the association of various troubles, all having a psychic origin, have lost a quarter, a third, and sometimes a half of their weight. The affection which has driven them to this point may have lasted months, sometimes years. Let it go on too long and death will occur, either from inanition or from secondary tuberculosis. However, it is a case of nothing but a purely psychic affection of which the mechanisms are of many kinds.

Sometimes we meet individuals afflicted with well-defined characteristic psychoses who will not eat. Such are the melancholies who think they can commit suicide by doing without food. There are also those with persecutory delusions, who are overcome by the fear of being poisoned. Other subjects, such as the major deliria, do not eat, because their delirium is sufficiently intense to inhibit — temporarily — all peripheral sensations. All these patients, once the delusional idea has disappeared, are able to be fed up immediately, and in an intensive manner. These do not come within the limits of our study. The mental repi'esentation of appetite is neither actually nor virtually lost to them.

Neither shall we consider those apparent cases of mental anorexia which we find in certain hysterics who affect anorexia in public, but who eat on the sly.

True mental anorexia consists in the progressive loss of the mental representation of appetite.

For the moment that the inhibition of the psychic phenomenon which constitutes appetite is accompanied by an inhibition of the physical phenomenon — which is the feeling of bodily hunger — mental anorexia is established.

We shall study under the name of secondary mental anorexia those cases where the taking of food has been restricted with the idea of relieving some former digestive trouble. We shall give the name primary mental anorexia to those cases in which originally, and often voluntarily, the amount of food taken by the individual had, for some cause or other, been diminished. The common characteristic of all these patients is that, when their affection has reached a certain stage, they get to the point where if they should want to cat they could not, for they no longer have any feeling of hunger.

In primary mental anorexia two classes of facte must be considered. Sometimes the loss of appetite is emotional in its origin. Sometimes the reduction of food has been purely voluntary at the start.

Here, for example, as an illustration of the first class, is the case of a woman, fifty years of age, who has been a widow for several months. Her children live at some distance from her, and are not of much comfort to her. Her whole life was wrapped up in her husband. She is extremely thin. She weighs seventy-nine pounds, instead of her normal weight, which is in the neighborhood of one hundred and ten pounds. This loss of weight has been rapid. It has taken place in three months. She says she is actually incapable of eating. Her food sticks in her throat. She chews it indefinitely, and cannot get up courage to swallow it. An egg, two or three cups of milk, and a few mouthfuls of bread are her daily diet. It is the typical picture of mental anorexia. How did it start? Here is a case which is purely emotional in its origin, and this is how it happened. This woman continued to occupy the apartment where she had lived with her husband. When she sat down to her meals, his image would rise before her, as would be natural from the association of ideas, bringing a whole train of emotional sensations, constriction of the throat, a feeling of weight in the stomach, lack of appetite, etc. She would get up from the table without having really eaten anything. By degrees this restriction of diet which was purely emotional in its origin brought her at last to the condition of mental anorexia.

Cases of this kind are extremely numerous. Grief, disappointment in love, or unhappiness in marriage are very often the emotional source of the most characteristic mental anorexias.

In other cases the restriction is at first voluntary and intentional. It is often due to coquetry.

A young girl, nineteen years of age, weighing one hundred and forty-three pounds, thought she was a little too heavy, so she tried to grow thin. She succeeded in losing twenty pounds in five months. In the meantime she became engaged. Her future husband thought she was too thin; so she tried to regain all, or at least some, of her lost weight, but her efforts were useless. She could no longer eat, and she continued to grow thinner. Her previous struggle against her appetite had caused her to become an anorexic.

Mysticism, is responsible for a great many cases of mental anorexia. Regular fasting, instead of an occasional fast, is what induces it. Here is an example of a young lady, who hitherto had had no psychopathic taint. She had a brother who in several months was to come up for his examination in a great government school. She took a vow that she would eat nothing but the smallest portion that would suffice her.

Being very scrupulous she observed her fast qualitatively as well as quantitatively. The brother passed his examination and entered the school, and the young girl tried to eat as she had formerly done. But her appetite was no longer there, and she was obliged to spend several months in a sanitarium to cure the mental anorexia, which had reduced her to the last degree of emaciation.

Following the same idea, we once knew of a young man who intended to enter a monastery. Fearing that he would not be able to stand the fasts which this life imposed, and yet desirous of following his call, he thought that he would make a sort of test, and put himself through some privations in the matter of food. In a few months his efforts were rewarded by an attack of mental anorexia.

This case is similar to those of notable fasters who some years ago made a regular sporting profession of fasting, and who would go twenty or thirty days without eating.

Finally there are cases of mental anorexia whose origin is wholly different. This anorexia is of a social origin. It is the anorexia of poor people, who are obliged by the necessities of life to deprive themselves to such a degree that, when the illness or lack of employment which has caused these privations has disappeared, they find it impossible to take food again.

Patients afflicted with primary anorexia have this special characteristic, that in spite of their extreme thinness, they keep a good deal of their strength. We have seen, in illustration of this, young girls, who had gone down to fifty-five or sixty-five pounds in weight, continuing to live as their friends did, going for long walks and playing tennis.

Organically, these patients, as a rule, present only one important symptom, namely the suppression of the menses.

Secondary mental anorexia differs from primary mental anorexia in a certain number of ways. First of all, in this form the two sexes may be equally attacked, while, as we have already indicated, primary mental anorexia is found chiefly in women. In secondary mental anorexia, while the clinical picture is the same, as far as the loss of weight goes, the strength of the patient, on the contrary, is very much less. When they are lying down they are hardly able to raise themselves up. This is because it depends upon disturbances which have taken place very slowly. The alimentary restriction is only secondary. These are the false gastropaths or enteropaths who, either spontaneously or, alas, more often by reason of medical prescriptions, have entered upon a very strict regime, which they have followed only too well. By reason of constantly noticing themselves and classifying their foods and rejecting all kinds that they think they cannot digest, they finally manage to live on an incredibly small amount. Alimentary phobias creep in, and without showing any other intellectual disturbances, or any other modifications of character, these patients become rebellious, or make a great scene whenever anyone tries to make them eat. There are some who subsist on a quarter of an apple. For others two or three prunes form their daily rations. A certain one took two or three eggs a day. We saw another who had gotten to the point where she could live if she had a bowl of sugar water beside her. She dipped a paint brush into it from time to time, and moistened her lips with it. This was her only nourishment.

There are, unfortunately, only too many examples of cases where these conditions have been brought about by dietaiy regulations prescribed by some ill-advised physician. These patients, in fact, will often say to you, " It is no wonder that I eat so little, for they have steadily cut down the quantity of my food on the one hand, and on the other hand, they have put me on a diet from which they have cut out everything I like to eat."